Doctor as scientist, healer, magician, business entrepreneur, small shopkeeper, or assembly line worker — which is it? (Essay 30)

Doctor as scientist, healer, magician, business entrepreneur, small shopkeeper, or assembly line worker — which is it?

Bernard Lown, MD
June 26, 2012

In the tumultuous debate about health care convulsing public discourse, the focus is on escalating costs and possible economic remedies. But the innards of the ailing system have not been adequately exposed to searching analysis.

Health care systems are stressed by a burgeoning global population, multiplying in my lifetime 3.5 fold, to seven billion. They are distorted by the increasing dominance of market forces, focused primarily on profitability rather than patients’ well-being. They are mal-aligned by growing inequities in wealth between developed and developing countries, and by the decimation of the middle classes in industrialized countries. They are challenged by adverse ecological transformations that afflict us with puzzling new diseases as well as with drug-resistant microbes and viruses. Life on earth is undermined by the chemicalization of ecosystems, the pollution of air and water, and climate change threatening the planet as a comfortable habitat for human civilization. This veritable witches’ brew has other malign elements, most noteworthy the commoditization of everything within market reach, including art, education, and religion — ensnaring the most intimate of human interactions as well as our inner selves. The result is the alienation of people from their communities, families, friends, and ultimately themselves.

The doctor’s role is further burdened by an aging population. The life span in the United States has increased by a formidable 25 years in the past century, with the most rapidly growing segment of the population now being those over 85. As a result doctors confront numerous comorbidities that may be ameliorated but rarely cured. These chronic afflictions are affected by social determinants such as class, race, gender, income, and education and are best prevented or delayed by public health interventions at the community level. Yet governments allocate minimal if any resources to the public health sector.

In this new age, what is the physician’s role in promoting health and preventing illness? In fact, doctors take on a mishmash of possible roles, as suggested by the title of this essay. The rapid industrialization of health care is forcing physicians out of self-employment into large corporate or hospital-sponsored clinics. Though high salaried, their status is that of an employee, not uncommonly subjected to the time pressures of an assembly line. Those who are still hanging on in private, solo, or small-group practices are reduced to the precarious economic status of small shopkeepers. Those who are highly proficient in cutting-edge medical technologies have much institutional bargaining power and acquire influential entrepreneurial roles that provide them with a say in the division of abundant financial spoils. Yet whatever a physician’s role, the self-image is that of a scientist in a discipline guided by cogent scientific evidence.

Medicine as a Science
Not only do doctors flaunt scientific pretensions, but the wider public is also convinced that medicine is a scientific discipline. I recall some years ago seeing a brilliant Harvard professor of the arts who presented with a complicated cardiovascular problem. After I spent an enormous time working through his byzantine medical history and performing a complete physical examination, he commented that never in his 70 years had he undergone such a thoroughgoing medical evaluation. He grew effusive when subjected to fluoroscopy with an antediluvian X-ray machine that resembled the cockpit of a B-52 bomber. His words stuck with me: “I now feel completely satisfied that you, doctor, are at the cutting edge of science.” I was deflated. His problem was defined by the history and confirmed by the physical examination. The fluoroscope should never have been used. We were both unnecessarily spewed with dangerous radiation. Knowing the size and shape of the cardiac silhouette added nothing to comprehending or managing his medical problem.

A clinical presentation partakes of two discrete yet indissolubly intertwined constituents. First is the objective illness, with an array of defining symptoms. Second is the patient’s subjective perception, the individualization of what is troubling. The patient demands that the former be cured and hopes the latter undergoes healing. In the case of an acute illness, like a cold or appendicitis, cure is foremost on the agenda. In the case of a chronic illness, the patient, aware of the intractability of the condition, craves healing.

Distinctive symptoms are shared with other patients with the same disease. They form a specific constellation leading to a precise diagnosis, an accepted therapy, an established course, and a predictable outcome. On the other hand, the subjective factors troubling the victim are distinctive, at times charged with formidable complexity and may not be shared with a single other inhabitant on planet Earth. Patients intuit an array of subjective factors and stresses that predispose as well as provoke the afflicting illness. These are psychological, interpersonal, and social and are likely to continue even after the illness is ameliorated or cured. No wonder that the practice of medicine, even in this scientific age, meanders often into the lush valley of snake oil dispensation.

Chronic medical conditions complicate the doctor’s mission, since therapy is optimal only when individualized. Adding further complexity is that a chronic illness does not march alone. Invariably it is accompanied by comorbidities. Additionally these are often accompanied by the physical and mental deteriorations of aging. Clinical judgment is dominated by epidemiological and statistical data. But as I have commented in an earlier essay, statistical fact is not the same as individual truth. Epidemiological data, irrespective of how comprehensive and how large the sample size, may not be relevant for an individual patient. Each person is not only different but also different in a unique way. Science rarely informs about the unique particularities of an afflicted individual. However, the practice of clinical medicine involves only individuals.

Science, in order to account for endlessly diverse biological phenomena, ignores individual uniqueness and concentrates on commonalities. Its strength derives from being able to isolate and study key variables within complex systems. This type of reductionism permits the abstraction of underlying essential laws.

The common view that given enough information everything is predictable is untrue. One can never have all the needed information. Indeed, traditional science cannot predict the behavior of complex systems. In recent times this has been illuminated by the so-called chaos theory. Edward Lorenz, a mathematician and meteorologist at the Massachusetts Institute of Technology, launched a revolution in scientific thinking when he showed that the ability to predict long-range weather patterns would require individual data on every molecule in the earth’s atmosphere.

In every complex system, according to Lorenz’s coinage, there is a “butterfly effect.”(1) He mused that the formation of a hurricane may depend on a distant butterfly having flapped its wings weeks earlier. The outcome in nonlinear systems sensitively depends on initial conditions. In complex biological systems, initial conditions are unknowable. When confronting clinical complexity, the strength of scientific reductionism is its Achilles’ heel.

Irrespective of the amount of data, some complex systems operate unpredictably. Poets have long had a far clearer insight than scientists, when suggesting that the falling of a leaf may cause a distant star to twinkle. Medicine is the asymptotic science of human beings, where the asymptote is the art.

Doctoring as an Art
If medicine is not a science and doctors are not scientists, how does a doctor come to know what truly ails a patient? Asking this does not imply that science is irrelevant to doctoring. On the contrary, we never have enough of science. But science alone is not enough. In dealing with the extreme complexity of human beings, art complements science in exposing the nature of what ails. Aristotle perceived this truth more than 2,000 years ago when he wrote, “The aim of art is to present not the outward appearance of things but their inner significance.” The physician is always searching for that inner significance. The patient is the sole possessor of what the doctor needs to know. This knowledge can be exposed largely through a trusting and intimate partnership between the two.

The art of communication looms supreme. I am convinced that the partnership begins through intense listening to a patient. Listening is the most complex, most informative, and most rewarding activity for both doctor and patient. The doctor aims to grasp not only what ails but also why it ails in a particular manner. I am well aware of the inadequacy of language for communicating complex and conflicting emotional tonalities. Reaching out to another human being is hampered by the very fluidity of the meaning of words. The gist of a word, especially of a phrase, is shaped by age, affected by class, altered by the level of education, modified by gender, race, ethnicity, and even by momentary mood changes. Facile and inexact, words rarely capture the deeper intent of what we yearn to share. Evolution, at least partially, has equipped us to circumvent these limitations.(2) We are endowed with additional expressive venues to tune the shortfall in words. We each possess a powerful nonverbal repertoire of body language and facial expressions. Communication is thereby finely adjusted by a diversity of signals. These instantaneous messaging systems operate across cultures and are evident even in infants and toddlers. But to overcome the multiple sources of static and tune in to a particular patient’s wave length, a doctor needs to convey a sense of exclusive attentiveness. This is best achieved by making the patient aware of the adequate, unintruded time that has been allotted for the visit.

Time does not have to be everlasting for a doctor to be responsive to a patient. It can be stretched through a host of measures — for example, by facing the patient at eye level; by banning intrusions by secretaries, technicians, or colleagues; and by not interrupting a patient’s narrative. These straightforward measures intensify time without extending it. I learned this after having been operated on for a ruptured intervertebral disk. The neurosurgeon visited in the late afternoon. Unlike the other doctors on the surgical service, he seemed to spend unlimited time with me. When once clocking his visit, I was astonished that it lasted a meager five minutes, approximately the same amount of time as the other doctors spent. The difference was that he slouched down in a comfortable chair close to my bed, appeared unhurried, didn’t barrage me with staccato, robotic questions, and seemed eager to let my narrative flow uninterrupted. This was 40 years ago, I still savor recalling those pleasant chats.

To listen fully requires attentiveness to seemingly insignificant clues. These stir the compass needle of the discussion, at times, in unanticipated directions. The doctor has to yield authority to the patient as chief navigator. This invariably leads to information that matters to the patient and enables a doctor to make sense of the unfolding narrative.

I recall the visit of KM, a heavy-set Irish American woman in her late 30s. She sought a second opinion about the need to undergo coronary artery angiography for “intractable angina pectoris.” This medical opinion was offered by cardiologists in two of Boston’s leading hospitals. KM was experiencing nearly daily intense left-side chest pain while hurrying in the morning. She was terrified of dropping dead from a heart attack. She knew much about the heart, being both a nurse and having witnessed this happening to her stressed-out father just short of his 50th birthday. KM related that an exercise test confirmed the diagnosis of heart disease as her voice faded into a hopeless nowhere. Yet she lacked risk factors for cardiovascular disease. Her blood pressure, cholesterol, and blood sugar were well within a normal range.

I asked which days she was free of “angina.” She responded on weekends. Walking the first thing in the morning, probably while going to work, pointed to a possible provocative factor. My next question was, “Do you have trouble at work?” Her quick response was that she loved her work. As a matter of fact, her job helped maintain her sanity. I continued to probe. What was different about weekends? She indicated that she was far less stressed. She didn’t have to ready her two children for school or prepare lunch for her husband. Then, as an afterthought, she added that on the weekend she visited her mother in the afternoons instead of mornings on her way to work. Until that moment the conversation had had an easy flow. Now she seemed uncomfortable and turned her face away.

Before I could explore this matter, she took charge of the discussion again. She went into a jeremiad of what would happen to her family if she needed coronary artery bypass surgery. As their health insurance was inadequate, the family would go bankrupt. She was the main breadwinner, so if she were to go even a few weeks without work, they would default on their mortgage payments. Then this proud woman began to weep as she contemplated their homelessness.

To get off this muddy terrain, I asked her to point where the pain was. She moved her right index finger to a spot above her left breast. I sighed with relief. This was a purposefully misleading cue. A person who experiences angina when asked to point will use the entire hand and begin to close it as though making a fist and invariably position it on the breastbone. So far so good.

I forged into the sensitive terrain with a neutral question. ”Does your mother live close by?” Indeed her mother lived in the same block. It was a very short walk. Then as if to preempt my next question, she asserted, “But I really rush, you know, doctor, with all I have to do: to help my mother dress, prepare her breakfast, do various other chores for her, and make sure I am not late for work.”

Then a question that came from nowhere: “What do you truly enjoy doing?” Her face lit up as she began to speak, and I felt an inner glow as I listened. “I love to cross-country ski in Maine on a very cold sunny day with my girlfriend. You know, she is an Olympic-caliber skier. She sets quite an impossible pace. Even though the temperature is subzero, I am in a sweat.”

“Do you experience any chest pain while skiing?” I ask innocently.

She looked at me as though I were the village idiot.

“Of course not. Why should I?”

One more decisive piece of evidence was needed to settle the diagnosis. During the physical examination I pressed with my index finger on the very same spot she earlier pointed to. She let out an “ouch!” It established without a doubt that she did not have angina. The chest wall is not tender in those having angina. We were now ready to pursue KM’s relation with her widowed mother.

KM was nine when her father died suddenly. Her mother, always distraught in responding to the needs of five children, became dysfunctional. KM was compelled to shoulder adult responsibilities. She married young to escape, but as she was the oldest daughter, her mother’s stroke and ensuing disability burdened her once again.

I communicated the good news decisively. The chest discomfort was not due to the heart. She did not need to undergo coronary angiography. She did not need to be followed by a cardiologist. She could come back to see me when she was 60 — 21 years hence — if I was still alive. I told her that it was about time that she shared the responsibility of caring for her mother with her four siblings. A month later when I telephoned her, she was entirely free of “angina” and even the chest wall tenderness had disappeared.

There is a magic to attentive listening. We learn to select just the right phrase that communicates to the other that we have calibrated to their intimate rhythms. I recall a physician patient who was in a continuous panic provoked by a flurry of disordered heart rhythms. His heartbeat was chaotic with skips and mini-bouts of tachycardia. He had consulted four cardiologists and tried a diversity of antiarrhythmic drugs. He gave up exercising, to which he had been fanatically committed. He abstained from sex, stopped seeing patients, abandoned friends, became more reclusive, and was increasingly worried that his heart would drive him to suicide. He had in effect crawled into his heart and was chewing at it. After listening to him for nearly an hour, I blurted out that if he was to regain the respect of his heart he needed to be kind to his heart. At the time I uttered this judgment, it sounded profound. A minute later I was embarrassed by the pompous windiness of my words.

Four years later he returned, now completely free of arrhythmia, off all drugs, and back to a normal life. I asked him how he had done this. The response: “You did it by teaching me how to be kind to my own heart.”

Or, after listening to an Iranian woman with normal coronary arteries suffering chest pain that no doctor had been able to alleviate, I learned that her husband lived in Tehran and her two children resided away from Boston. I expostulated at last, “You are neither here nor there — where are you?” Those few words sowed the seeds of trust. Her demeanor underwent a change from restraint verging on hostility to “I know, doctor, that you will help me.”

From extensive observations and personal experience as a patient, I am dismayed at the displacement of history taking by checklists filled out by inadequately trained health personnel. The physical examination has been largely abandoned. If the doctor is a scientist, one can understand the shying away from the artsy, the subjective, the cultic, the judgmental soft data provided by talk and feel. This abandonment of traditional doctoring begins in medical schools and is deeply ingrained through hospital rotations.(3)

Medical Schools — Citadels of Science
Students attending medical school are largely drawn from the affluent sector of the population. Yet upon matriculating into this demanding profession, a good many, perhaps the majority, are charged with idealism. Their wish to do good exceeds their desire to merely do well. One encounters a strange paradox: medical schools, instead of honing the innate humanity of their students, deplete their commitment to caring. Their outlook is markedly transformed in the journey from neophyte to MD. I had occasion to witness this phenomenon at three junctures in my medical career, each two decades apart.

Entering Johns Hopkins Medical School (JHMS) in 1942, I immediately searched for social involvement beyond the anatomy dissecting table. Students were then under enormous time pressure. Because of the war, the curriculum was compressed into three years without breaks or holidays. Nevertheless, I invested a great amount of time to reactivate the JHMS chapter of the Association of Interns and Medical Students (AIMS). It was then regarded as a radical organization, since AIMS agitated for admitting women and Jews to medical schools, urged that interns and residents be paid a living wage, and supported a single-payer national health service. From a freshman class of 67 students, we recruited 30 members. Among sophomores the number of activists was reduced to 5. Only one brave soul joined our ranks as a junior, and we had not a single member among seniors. This pattern of membership prevailed in medical schools across the country.

In 1962 a small group of Boston doctors launched the Physicians for Social Responsibility to oppose the threat of nuclear annihilation. The pattern of membership at Harvard Medical School was nearly identical to that of JHMS 20 years earlier. In 1981, together with Soviet colleagues, we organized a global movement to alert the public of the mounting danger of a nuclear Armageddon.(4) Within four years after its founding, the International Physicians for the Prevention of Nuclear War gained a Nobel Peace Prize. It could not have happened without the enthusiasm and unwavering dedication of a large cadre of first-year Harvard Medical School students. Third- and fourth-year students were notably absent.

For 50 years I rounded several days a week at the Brigham and Women’s Hospital. This involved teaching house staff and Harvard medical students. Over this half century empathy among the aspiring physicians declined noticeably. At the same time they increasingly exhibited a fixation on cutting-edge technologies. I recall rounding with a very bright third-year Harvard Medical School student. We examined a patient with rheumatic heart disease. Excitedly I urged her to auscultate the heart to listen for the rumbling diastolic murmur of mitral stenosis. She listened intensely, then inquired with a baffled look, “How can you be certain that you hear a murmur, when you have not seen the echocardiogram?”

Medical students are not instructed on the boundaries or limits of science. They are taught little if anything about ministering to the dying patient. The young doctor is conditioned to view death as a mark of failure, the ultimate sacrilege in the temple of science. The consequences are frequently gruesome and costly. At the coronary care unit I was directing, a patient arrived with severe congestive heart failure, his fourth documented heart attack. Very little heart muscle was left intact. The cardiac ejection fraction hovered around 10 percent.(5) When I arrived, there was a hubbub of activity. Excitement reigned as the patient was readied for angiography and bypass surgery. Doctors were hurrying in and out of his room. After discussing the situation with the family, I concluded that further medical interventions were unwarranted. A disquieting silence followed in the clinic. Over the next two hours while the patient was alive not a single doctor entered his room! Death, the enemy, had gained a shameful victory, which these young warriors lacked the courage to acknowledge.

Many vital subjects are covered en passant or neglected entirely. Examining the medical curriculum, one would conclude that nutrition is not a significant factor in human health nor is it implicated in many of the prevailing chronic diseases. Few if any students are familiar with the ubiquity of sodium in processed food. I have not encountered a single Harvard Medical School student who was aware of the amount of sodium in a slice of bread. Poverty has been proclaimed by the World Health Organization as the leading single causal factor in both acute and chronic disease. Yet little of the economics of health care or the social determinants of disease are part of the medical curriculum. Doctors are ill informed about the exorbitant costs of drugs and rarely prescribe generics. They are not aware of opportunity costs: namely, that money expended on expensive drugs or procedures may deprive patients of food and divert funds from educating the children in their communities.

The distinguished Indian cardiologist Srinath Reddy has written of the five missing Es in medical education: namely, epidemiology, economics, ethics, empathy, and engagement.(6) The most glaring lacuna, in my mind, is the lack of communication skills. As a result doctors are uneasy about spending time with patients. This is reflected in the lack of skill in obtaining a clinical history or doing a simple physical examination.(3) The metamorphosis to medical technocracy begins in the third year, when students begin clinical rotations in hospitals. Why waste time questioning fallible, loquacious patients when one can image the very source of their pathology? Instead of retaining the human core of the medical enterprise, the baby has been tossed out with the bathwater.

A century ago an astute physician alerted the medical community about this very problem.(7) Dr. Alfred Worcester of Waltham, Massachusetts, wrote an essay titled “Past and Present Methods in the Practice of Medicine” in the Boston Medical and Surgical Journal in 1912 that describes this cascading trade-off. He asserted that the doctor of old “knew more about patients than many medical students of today ever will know.” Worcester continued, “In the modern medical school science is enthroned. Carried away by the brilliance of etiological discoveries, the whole strength of the school is devoted to the study of diseases. The art of medical practice is not taught; even its existence is hardly recognized. And in consequence the graduates of the medical schools of today are not properly fitted for the practice of their profession. … It is when dealing with the mysteries of life that his science fails him. He has not been taught the therapeutic value of sympathy and of encouragement. … wherever knowledge of disease is needed, there the modern doctor excels. But his training has not fitted him to be a physician.”

Medical school faculties resent any encroachment of their fiefdom. Yet much of the science learned in the first two years of medical school is soon forgotten. This is largely due to its irrelevance to the demands of a clinical practice. Thus, the curriculum could be reconfigured to address the neglected challenges of humanism and public health precepts and to acquaint students with the critical social determinants of disease.

At present medical schools and hospitals prepare doctors to become journeymen in science and managers of complex biotechnologies. Little of the art of doctoring is imparted. The abandonment of patient-focused health care was already evident a century ago. Now hosannas are raised to the primacy of the patient even as it has become an emptied trope. The distancing from patients paradoxically accelerates during the clinical years in medical school. This is the very time when impressionable students begin rotating through hospital services and assume some responsibility for the well-being of patients.

Hospitals as Factories of Biotechnology
Hospitals diminish the humanitarian titer of impressionable students, who are already frayed by medical school. Their role models are the chiefs of the numerous diverse specialties and particularly the chairpersons of medicine and surgery. These are invariably chosen because of their skill as researchers, demonstrated by voluminous bibliographies of scientific publications and by a track record in obtaining large research grants. Some of the chiefs have gained distinction as basic science investigators. Most are expert in some cutting-edge technology. In my experience few are skilled or wise clinicians. They rarely conduct teaching rounds at the bedside, though they are adept at delivering erudite lectures loaded with PowerPoint graphs of dense data. Emulating the conduct of the head honchos, the house staff conducts patient rounds in conference rooms. These concentrate on the profusion of laboratory data and organ imagings that are displayed on ubiquitous laptop screens. When attending physicians participate, they will focus on their own research findings and provide mini-scientific presentations. Visits to patients’ bedsides is done on the run. Much of the team may not even enter the room. There is no bedside teaching. Visiting a patient is ritualized as homage to an ancient rite, as relevant as the ubiquitous stethoscope that most display but few know how to use.

Hospitals are overwhelmed by the burgeoning bureaucracies necessary to keep the machinery of a mega-institution functioning, always sensitive to maximizing the bottom line. A significant objective, in this regard, is to navigate patients toward an expeditious discharge. Each patient’s diagnosis falls into some predesignated disease-related group, each with a fixed reimbursement and with a fixed duration of hospitalization. If the hospitalization is shortened, the institution is enriched — and impoverished if the time is exceeded. Patients are frequently out before they are truly in. House staff, let alone medical students, do not have opportunity to get to know a patient as a human being even when their intention is to do so. This ignorance is highlighted by referring to a patient not by name but by diseased organ: the cardiac, the kidney, or the liver patient.

A major challenge for a medical student is comprehending the torrent of data from a hospital’s diverse technologies. Some of these miraculously expose the most intimate parts of human anatomy. Why bother with errant locution or ausculting for an ill-perceived heart murmur when one can view the very diseased heart valve three-dimensionally in full motion? The student is additionally attracted to these technologies because they are in fact shortcuts to clinical experience that is secured only after years of practice. Furthermore, even a neophyte medical student quickly recognizes the rich fiscal rewards for those who are technologically skilled. The more complex the technology, the more handsome the reimbursement for the physician specialist, frequently tenfold or more than that for time spent in obtaining a history or performing a physical examination. A majority of students are burdened with medical school debt. Specializing, namely, gaining skill in a highly remunerated technology, not only rapidly unburdens debt but also enables one to live well while seemingly still doing good.

For the patient, the modern hospital is both a blessing and an abomination. The efficiency of the modern operating room, the minimization of discomfort afforded by scientifically rendered anesthesia, the careful monitoring of patients in postoperative recovery, the control of pain and discomfort, have revolutionized care. Not to be unmentioned are the many miracle cures for formerly deadly diseases. I am old enough to recall the nearly 100 percent mortality accompanying subacute bacterial endocarditis. Such an infection of a heart valve is now largely curable.

But those afflicted with chronic disease who also suffer from multiple comorbidities — as do most of the elderly who constitute a significant percentage of hospital bed occupancy — commonly feel a sense of abandonment. Patients rarely know who their doctors are. They are usually managed not by a single physician but by a team. The primary care physician does not make hospital visits. Bedside nursing is more PR than reality. Nurses are preoccupied with tracking the expenditure of resources and making sure that specific algorithms, safety codes, and multiple protocols are adequately adhered to. Forgotten are the backrub, the encouraging word, the accompanied walk, the rearrangement of sweaty pillows, the helping hand into a comfortable chair, the provision of ice chips or an urgently needed urinal.

In a recent hospitalization, I awoke early in the morning and had to urinate. There was no urinal on-site. An IV, a naso-gastric suction tube, and ECG monitor leads tethered me in immobility. The call button had fallen under the bed. Shouting could not penetrate the nursing station hubbub of monitor beeps, alarms, pages, call buttons, telephones, and the like. Fortunately a cell phone was within reach. I woke my wife, who called the nursing station to deliver the blessed urinal. Many patients have confided that they will not be hospitalized without a family member moving in with them.

The Urgency of a Medical Renaissance
I am well aware of H. L. Mencken’s dictum “For every complex problem there is a simple solution and it is always wrong.” My solution, therefore, is not at all simple: It is to promote a medical renaissance. Central to this goal is recultivation of the doctor-patient relationship. Two conceptual frameworks need integration, namely, that of illness and of disease — the former is what troubles the patient; the latter is the organismal dysfunction. The capacity to integrate illness and disease requires negotiation between two experts: the doctor and the patient. The physician brings expert knowledge of dysfunctioning biology as well as an appreciation of the general topography of disease; the patient contributes indispensable knowledge of the problem not available from anyone else in the big wide world. In fact, the patient is the sole repository of decisive evidence that can lead to the correct diagnosis of the disease as well as being an indispensable guide to the proper management of the illness.

The Renaissance, beginning in 14th-century Florence, released a flourishing of humanism out of a cocoon of oppressive religiosity that characterized the Dark Ages. We need to free ourselves of a similarly oppressive belief system, the all-pervasive conviction that markets can regulate all human interactions. These beliefs are anchored in myth and propelled by self-interest. They have ceased to serve the public good. Central to a market society is the stimulation of wants and artificial needs. The result is the commoditization of everything in sight, including our most intimate emotions. Doctoring has not been spared. In health care the corporate sector has discovered the ideal commodity. Unlike other commodities the consumer, qua patient, can never be sated. Every aspect in the human life cycle, every twist and turn in the aging process to the inevitable dissolution and death, every uncomfortable emotion, lends itself to medicalization. The dysfunctionality of health care in the United States in no small measure relates to market dominance.

Therein lies the contradiction. Permitting free rein to marketers in the health industry sinks the entire economy. Over decades the rise in health costs has exceeded the inflation of other goods and services. It has now reached 18 percent of our gross national product and is diverting investment from numerous vital sectors of the economy. To save the leaking hulk of an increasingly unseaworthy ship of state, the captains of industry might well be ready to throw overboard some esteemed passengers, not excluding those in the health care business. This emerging zeitgeist makes possible deep change. High on the agenda should be the humanization of health care.

Let’s recall patient MK to illustrate the economic sense of such a move. Had she undergone the cardiac catheterization, a modest coronary artery narrowing might have been detected, which in the prevailing medical culture would have supported the misdiagnosis of angina. This would have lent momentum for intervention. The cost would have been exorbitant and would not have ended with the procedure. Frequent surveillance by cardiologists, with costly annual nuclear studies of the heart, would have continued over 40 years of her likely life expectancy. Can anyone venture to estimate the cost? Social costs would have come as well. Indubitably she would have not been able to pay her medical bills and would have lost her home and perhaps her job. She would then become a recipient of Medicaid, paid by taxpayers. Yet the current system does not reimburse a doctor for a conversation with a patient but instead handsomely rewards the path not taken with MK. How crazy and corrupt can a system grow before an informed citizenry consigns it to the junkyard of history? Do you still doubt we need a Renaissance in medicine?(8)

5. Ejection fraction (EF) refers to the volume of blood ejected with each heartbeat compared to the capacity of the left ventricle. Below 50 percent is abnormal. One rarely encounters EFs of less than 20 percent.

15 responses to “Doctor as scientist, healer, magician, business entrepreneur, small shopkeeper, or assembly line worker — which is it? (Essay 30)”

This post makes me want to stand up and cheer! Way past time for the pendulum to swing back from techno and market worship to the central role of a true and healing physician-patient relationship. May it happen soon.

The letter below was sent with the above essay to about 100 friends. Periodically I will post a relevant response from a friend

Dear Friends,

Reflecting on a long life, it seems that the choices I have made were propelled by a sense of debt to society, Most likely these emanated from the cultural legacy of Jewish guilt. Whatever the cause, or however the reckoning as to the magnitude of repayment due, it is now or never. So how can it be done with most worth and least pain?

Perhaps with some final teaching moment? But in which domain- medicine, peace activism, antinuclearism, progressive politics, avid environmentalism, struggles against dehumanizing markets, focusing on the growing North-South divide, or the cultural buffeting encountered in migrating from a slow paced European shtetel to the jet propelled American all consuming hubbub?

On long reflection, I find greatest savor in medicine. The reasons are many. Indeed, other than with Louise, I have spent the largest chunk of waking hour time consumed by medicine. Indeed since entry in medical school in 1942, my life has been intimately entwined with this profession. Fifteen years I spent as student mastering the science and the art. For 50 years thereafter, I was consumed being clinical practitioner, researcher and teacher and the last five years I have been entangled as patient with episodic hospitalizations. This panoramic experience has provided a significantly rounded view of the limitations and the deep rewards of doctoring.

I am propelled to explore a number of issues from such a perspective for a far more meaningful reason. I have become increasingly persuaded that resolving the deepening crisis in health care requires restoring abandoned humanism to doctoring. At the same time it may prove prescriptive to resolving the global economic crisis. This sounds overly silly on quick read (since all of us are invariably in a rush). Bear with me. The first essay that launches this argument.

Dear Dr. Lown,
I am a medical intern from Kerala, India. I have read the Lost art of Medicine- it was indeed a life changing book. It made me aware of the complexities of the profession i am into. It is high time the humane side of ancient healers is restored to modern medicine

First of all, congratulations on writing such an outstanding essay! I can’t believe that I never took the time to reach your blog…many factors, I’m sure. I have had many trials and tribulations since my catalytic experience as a member of the board of the Ad Hoc Committee to Defend Health Care and my experience of carting all of the petitions to the Secretary of State’s office to get Proposition 5 on the Massachusetts ballot that year. For multiple uncomfortable reasons I am no longer practicing medicine…part of my soul is begging to return, particularly after reading your essay this morning. I would like to have the opportunity to meet with you to recall old times and investigate what I can to address so many of the issues you discuss in this essay. Your call to action has motivated me again. I treasure my personal copy of “The Lost Art of Healing” which you graciously signed for me at one of our first meetings at Faneuil Hall several years ago, the honor of attending Ad Hoc Committee meetings with you, getting to know you personally, and the honor of being on the Board of the Ad Hoc Committee before I relocated to South Carolina.

After best part of 25 years as an NHS GP in the North of England I am saddened to know that All you describe is now equally applicable here but thanks for the wisdom on listening ,and a beautifully written piece that I will use in my teaching

Dear Dr. Lown: I’d like to add a question – In this situation of ‘real doctors desert’, what kind of patient self-support system could be recommended? We have translated British “Family Doctor” (Dorling Kindersley, Ed. by Tony Smith).The diagnostic algorithms described in this book can lead the patient to right steps, for example, straight to the cardiologist. It can protect the patient as well as the collection of EKG in his hands.
Thank you
Nikita Shklovskiy-Kordi, MD